---
title: "Molina Healthcare of South Carolina ABA coverage: the intake guide."
url: "https://carelu.com/payers/molina-healthcare-south-carolina"
markdown_url: "https://carelu.com/payers/molina-healthcare-south-carolina.md"
state: SC (South Carolina)
payer: Molina Healthcare of South Carolina
kind: Medicaid managed care plan (MCO)
parent_program: South Carolina Healthy Connections Medicaid
description: "How Molina Healthcare of South Carolina covers ABA for Healthy Connections Medicaid members: the 2026 pre-service review list, decision timeframes, appointment standards for autism therapy, claims limits and what intake should verify."
last_reviewed: October 2026
---

# Molina Healthcare of South Carolina ABA coverage: the intake guide.

_Payer Guide · Molina Healthcare · South Carolina · Last updated October 2026 · 9 primary sources_

> Molina’s SC Medicaid plan: ABA on its 2026 pre-service review list, a 7-day decision clock, 365-day filing; code-level rules live in its lookup tool.

Molina Healthcare of South Carolina is one of the five Healthy Connections Medicaid MCOs. Its 2026 provider manual lists autism spectrum disorder services as covered (behavior identification assessment, treatment by protocol, protocol modification and family guidance), and its pre-service review guide effective February 1, 2026 puts ABA for autism behind prior authorization. Molina publishes no South Carolina ABA policy of its own, so expect the SCDHHS ASD manual to be the reference point and confirm details with the plan.

This plan administers the **South Carolina Healthy Connections Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [South Carolina Healthy Connections Medicaid guide](https://carelu.com/payers/south-carolina-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Molina Prior Authorization Look-Up Tool or Molina SC prior authorizations, (855) 237-6178: check 97151 and 97152. [2]
- **Prior auth for treatment**: Yes: ABA for treatment of ASD is on Molina’s South Carolina Medicaid pre-service review (prior authorization) list effective 02/01/2026 [2]
- **Autism diagnosis required?**: Yes: the list covers ABA "for treatment of Autism Spectrum Disorder (ASD)," and the manual covers ASD services [2][1]

## At a glance

- **Covers ABA?:** Yes: BIA, adaptive behavior treatment, protocol modification, family guidance
- **Prior auth:** ABA for ASD is on the 2026 pre-service review list; codes in the look-up tool
- **Phone:** Prior authorizations incl. behavioral health: (855) 237-6178
- **Decision clock:** 7 calendar days standard; 72 hours urgent
- **Timely filing:** 365 days from the date of service
- **Licensure:** None in SC; BACB certification governs

## Coverage and prior authorization

The manual’s covered-services table lists "Autism Spectrum Disorder — Covered": behavior identification assessment, adaptive behavior treatment by protocol, adaptive behavior treatment with protocol modification and family adaptive behavior treatment guidance. The pre-service review guide (effective 02/01/2026) lists "Applied Behavioral Analysis (ABA) – for treatment of Autism Spectrum Disorder (ASD)" under behavioral health services requiring review and tells providers to "Refer to Molina’s Provider Website or Prior Authorization Look-Up Tool for specific codes." Prior authorizations, including behavioral health, go to (855) 237-6178. Molina sets an appointment standard for autism therapy services: routine visits within 15 business days, urgent within 48 hours. [1][2]

Molina says it will process "any non-urgent Prior Authorization requests no later than 7 calendar days following receipt of the request," and urgent requests within 72 hours, each extendable by up to 14 days. Claims are timely within "365 calendar days after the discharge for inpatient services or the Date of Service for outpatient services." [1][2]

## Claim filing and payment rules

Molina’s 2026 South Carolina Medicaid manual: claims are due "within 12 months/365 days after the discharge for inpatient services or the date of service for outpatient services," and "Corrected Claims must be sent within 365 calendar days of date of service of the Claim." When Molina is secondary, "the Provider must submit Claims to Molina within 12 months/365 days from date of service after final determination by the primary payer." Molina "will process the claim for service within 30 calendar days after receipt of Clean Claims," unless the provider agreement sets another schedule. Participating providers must enroll in EFT and ERA. The manual publishes no weekly check-run or cut-off schedule. [1]

## Intake gates

The questions that decide whether a family can start with Molina Healthcare of South Carolina, and what they have to bring.

- **Referral required?**: Follows the South Carolina Medicaid (SCDHHS) rule: ASD services "must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice under state law." For treatment, the manual recognizes three routes: a physician or LPHA refers a member with a prior-established ASD diagnosis to an ASD-network ABA provider or LIP; the member self-refers on that prior-established diagnosis; or a physician refers a member with presumptive eligibility (Section 8). Referrals "can be done via phone, email, fax and hard copy mail," and the provider's record must contain a "Referral form" alongside the BIA and signed IPOC. In practice the recommendation comes from the diagnosing evaluation: the comprehensive diagnostic assessment must list recommendations based on medical necessity, including a "Referral for applied behavior analysis therapy if indicated." The manual sets no validity period for the referral; the July 2026 ASD manual's initial-request packet carries the diagnostic assessment (or physician documentation of a Medical Care Home assessment or of presumptive eligibility) instead. Molina publishes no ABA-specific referral rule of its own: its 2026 provider manual only lists autism spectrum disorder services as covered, and its pre-service review guide says referrals to network specialists need no prior authorization while ABA itself does. [3][1][2]
- **Prior-auth decision time**: Non-urgent requests "no later than 7 calendar days following receipt," urgent within 72 hours; either may be extended by up to 14 calendar days. [1][6]
- **Other insurance (who pays first)**: "Medicaid is always the payer of last resort." If third-party liability exists, bill the primary payer and submit its EOB to Molina for secondary processing. [1][7]
- **Age limit** _(plan-dependent)_: Molina’s manual does not state an age for ABA. The SCDHHS ASD benefit, which the MCOs administer for their members, covers ages 0 through 20. [1][3]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178.
- **Who may diagnose** _(plan-dependent)_: Not stated by Molina. The SCDHHS manual limits ASD diagnosis to MD/DO, PhD/PsyD or LPES, in person. [1][3]
  - Ask the plan: Molina SC prior authorizations, (855) 237-6178.
- **Telehealth** _(plan-dependent)_: Molina publishes no ABA telehealth rule for South Carolina. The state baseline: Under the SCDHHS ASD manual (July 1, 2026), only two ABA codes may be delivered by telehealth: 97156 (family guidance), with the GT modifier and no extra authorization, and 97155 (protocol modification), only when the QIO approves it during prior authorization, for up to 25% of authorized and rendered 97155 units, for a member receiving in-home ABA in a rural location with limited access. Telehealth must be synchronous audio and video, GT goes in the secondary modifier position, and POS is 02 or 10. "The BIA can not be completed by telehealth," and 97152, 97153, 97154, 97157, 97158, 0362T and 0373T are not deliverable by telehealth. An ASD diagnosis made by telehealth is not valid. [1][3]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178: ask which ABA codes it pays by telehealth.
- **Diagnosis recency** _(ask the plan)_: Not stated by Molina. [1][2]
  - Ask the plan: Molina SC prior authorizations, (855) 237-6178: ask how recent the diagnostic evaluation must be.
- **Diagnostic tools required** _(ask the plan)_: Not stated by Molina. [1]
  - Ask the plan: Molina SC prior authorizations, (855) 237-6178: ask which instruments it expects.

## Delivery and billing rules

Coverage decides whether Molina Healthcare of South Carolina pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision** _(plan-dependent)_: Molina publishes no ABA supervision rule for South Carolina. The state baseline in the SCDHHS ASD manual: BACB supervision applies: "each RBT must be supervised for a minimum of 5% of the hours spent providing ABA services per month," with at least two face-to-face, real-time contacts a month, one of which observes the RBT with the member; that professional supervision is not billable. Caseload caps: a BCBA may carry 12 cases (16 with a BCaBA), a BCaBA 12, where 30–40 hours a week is one case, 10–25 hours half a case and under 10 hours a quarter case. A behavior technician gets one 90-day grace period to earn the RBT credential, and may work only in a clinic with a BCBA on site during it. [1][3]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178: ask whether the SCDHHS supervision and caseload rules apply to its network.
- **Place of service** _(plan-dependent)_: Molina publishes no ABA setting rule for South Carolina; the SCDHHS manual allows home, clinic and, with authorization, school and community settings. [1][3]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178: ask which POS codes it pays for ABA.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in the manual or the pre-service review guide. On ABA alongside other therapies, Molina publishes nothing of its own; the state baseline: the SCDHHS ASD manual's non-covered list is explicit — "Concurrent billing of 97153 with any other service or therapy is excluded except as detailed in Section 8," and Section 8's exceptions are ABA-with-ABA only. It also excludes "ABA services while the member is at another medical appointment," and, in the other direction, ABA treatment "that precludes, or requires the member's family to stop engaging with other critical supports … speech therapy, occupational therapy, or IDEA recommended school-based curriculum and supports." So speech and ABA can both continue, but not on the same clock time as a billed 97153 unit. The manual also binds providers to the National Correct Coding Initiative edits and related coding policy unless it says otherwise. [3][1][2]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178, or your provider agreement.
- **Daily limits / MUEs** _(ask the plan)_: Molina publishes no ABA unit limits for South Carolina. [1]
  - Ask the plan: Molina SC prior authorizations, (855) 237-6178: ask whether the SCDHHS section 8 limits apply.
- **Session-note signature** _(ask the plan)_: Molina publishes no ABA session-note signature rule for South Carolina. [1]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178, or the documentation standards in your agreement.
- **Bill as provider** _(ask the plan)_: Molina publishes no ABA rendering-provider rule for South Carolina. [1]
  - Ask the plan: Molina SC Provider Services, (855) 237-6178: ask whether RBT services bill under the supervising BCBA’s NPI.

## What intake should collect for Molina Healthcare of South Carolina

- **Member ID:** Confirm Molina Healthcare of South Carolina Medicaid (Molina also sells Marketplace plans).
- **Diagnostic report:** Have the full evaluation ready; Molina publishes no SC-specific diagnosis rule, so plan to the SCDHHS standard.
- **Other insurance:** Medicaid is payer of last resort; bill the primary and send its EOB.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### What are Molina South Carolina’s claim deadlines and payment time?

Initial and corrected claims: 365 days from the date of service. Secondary claims: within 365 days from the date of service after the primary payer’s final determination. Clean claims are processed within 30 calendar days of receipt. No check-run schedule is published.

### Does Molina Healthcare of South Carolina cover ABA?

Yes. Its 2026 manual lists autism spectrum disorder services as covered, and ABA for autism needs prior authorization.

### How do I find which ABA codes Molina SC requires authorization for?

The pre-service review guide lists ABA and points to Molina’s Prior Authorization Look-Up Tool for specific codes; call (855) 237-6178 if in doubt.

### How long does Molina SC take to decide?

Up to 7 calendar days for standard requests and 72 hours for urgent ones, with possible 14-day extensions.

## Primary sources

1. [Molina Healthcare of South Carolina — Medicaid Provider Manual 2026 (Molina media path)](https://myhealthinhand.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/sc/medicaid/manual_sc_ProviderHandbook.pdf)
2. [Molina Healthcare South Carolina Medicaid — Pre-Service Review Guide (effective 02/01/2026; Molina media path)](https://myhealthinhand.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/sc/medicaid/prior-authorization-pre-service-review-guide.pdf)
3. [SCDHHS — Autism Spectrum Disorder (ASD) Services Provider Manual (July 1, 2026)](https://www.scdhhs.gov/sites/dhhs/files/documents/ASD%20Services%20Provider%20Manual%207.1.26.pdf)
4. [SCDHHS Medicaid Bulletin MB# 26-015 — Updates to ASD Services Provider Manual (May 15, 2026; effective July 1, 2026)](https://www.scdhhs.gov/communications/updates-asd-services-provider-manual)
5. [SCDHHS — Managed Care Carve-in (Jan. 1, 2026; MCO prior-authorization and provider help lines)](https://scdhhs.gov/partners/managed-care/managed-care-carve)
6. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
7. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
8. [BACB — U.S. Licensure of Behavior Analysts (South Carolina not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
9. [Molina Healthcare of SC — Provider Communications (Palmetto Partners newsletter and announcements)](https://www.molinahealthcare.com/providers/sc/communications)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.